Nursing Elites

1. When dismissing a 5-year-old boy from the pediatrics unit, what type of seat belt restraint should the child wear as the parents drive the car to the front door of the hospital?

• A. A 5-point restraint in the back seat, facing backward
• B. A booster seat with a lap and shoulder belt in the back seat
• C. A lap belt in the back seat
• D. A lap and shoulder belt in the front seat

Correct answer: B

Rationale: A 5-year-old child riding in a car should use a restraint system for safety. The Centers for Disease Control and Prevention recommend that children under 13 years should not ride in the front seat of a car due to safety concerns. For a 5-year-old child, a booster seat with a lap and shoulder belt in the back seat is the most appropriate choice. This setup ensures proper protection and restraint for the child's size and age. Choice A is incorrect because a 5-point restraint system facing backward is not suitable for a 5-year-old child in a car. Choice C is incorrect as a lap belt alone does not provide adequate protection for a child of this age. Choice D is incorrect as children should not be seated in the front seat, especially at this young age.

2. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

• A. The admission orders are written.
• B. A blood culture is drawn.
• C. A complete blood count with differential is drawn.
• D. The parents arrive.

Correct answer: B

Rationale: Before starting antibiotics, a blood culture should be drawn to identify the causative organism. This step is crucial as antibiotics may interfere with the identification process. Drawing a complete blood count with differential or writing admission orders are important steps in patient care but are not as critical as obtaining a blood culture to guide appropriate antibiotic therapy. The arrival of the parents is not directly related to the immediate action required before starting antibiotics in this scenario.

3. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?

• A. ''This action of my lips helps to keep my airway open.''
• B. ''I can expel more air when I pucker up my lips to breathe out.''
• C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
• D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''

Correct answer: D

Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.

4. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

5. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?

• A. Ask the patient to take deep breaths to relax the abdominal musculature.
• B. Consider this finding as normal and proceed with the abdominal assessment.
• C. Increase the amount of strength used when attempting to percuss over the abdomen.
• D. Decrease the amount of strength used when attempting to percuss over the abdomen.

Correct answer: C

Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.

Similar Questions